3 Post Session Survey

[Program Name] Participant Post Program Survey
Today’s date:

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M M

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D D

Y

Y

Y

Y

Participant I.D. (first two letters of your first name, first two letters of last name, last two
numbers of your birth year): __ __ __ __ __ __
1. In general, would you say that your health is:
Excellent

Very good

Good

Fair

Poor

The next few questions ask about falls. By a fall, we mean when a person unintentionally
comes to rest on the ground or another lower level.
2. Since this program began, how many times have you fallen? O none O

times

a. If you fell since this program began, how many of these falls caused an injury? (By an
injury we mean the fall caused you to limit your regular activities for at least a day or to go see a
doctor.)
number of falls causing an injury

3. How fearful are you of falling?
Not at all

A little

Somewhat

4. Has this program reduced your fear of falling? O Yes

A lot
O No

5. Please mark the circle that tells us how sure you are that you can do the
following activities.
How sure are you that:

Very sure

Sure

Somewhat
sure

a. I can find a way to get up if I fall
b. I can find a way to reduce falls
c. I can protect myself if I fall
d. I can increase my physical strength
e. I can become more steady on my
feet

Please turn this paper over and fill out the other side.

Not at
all
sure

Participant Post Program Survey (continued)
6. During the last 4 weeks, to what extent has your concern about falling interfered
with your normal social activities with family, friends, neighbors or groups?
Extremely

Quite a bit

Moderately

Slightly

Not at all

7. Please tell us your thoughts about this program. Check one circle for each
question.
As a result of this program:
a. I feel more comfortable talking to my health
care provider about my medications and
other possible risks for falling
b. I feel more comfortable talking to my family
and friends about falling
c. I feel more comfortable increasing my
activity
d. I plan to continue exercising
e. I feel more satisfied with my life
f. I would recommend this program to a friend
or relative

Strongly
Agree

Agree

Disagree

Strongly
Disagree

O

O

O

O

O

O

O

O

O

O

O

O

O
O
O

O
O
O

O
O
O

O
O
O

8. Since this program began, what have you done to reduce your chance of a fall?
Check all that apply.

o Talked to a family member or friend about how I can reduce my risk of falling
o Talked to a health care provider about how I can reduce my risk of falling
o Had my vision checked
o Had my medications reviewed by a health care provider or pharmacist
o Participated in another fall prevention program in my community
o Did exercises I learned in this program at home
o Made changes in my home to reduce my risk of falling (for example, secured
rugs or improved lighting)